Mental Illness And Aging Research Paper

Policy

Aging is a time of diminishing mental as well as physical capacities, and cognitive aging is best understood as simply another phase of life. Some people age more successfully than others, and many find new and deeper satisfaction in later life. But aging also brings with it the threat of serious mental health conditions, including dementia as well as depression, anxiety and sometimes psychosis, which will require greater attention as our society ages. Mental Health America (MHA) advocates studying and funding medical and psychosocial interventions to help sustain our mental health and quality of life as we age, and acting to maintain and recover wellness.

In coping with the mental health conditions associated with aging, as with any other serious mental health condition, “recovery” should be the goal. While a positive attitude can make an enormous difference in aging well, mental illnesses including dementia, which the Diagnostic and Statistical Manual of Mental Disorders -5[2] (DSM) refers to as “mild” and “major” “neurocognitive disorders,” are not “normal” parts of aging, and should be identified and treated once it is clear that there is a probable disorder. This is as true with dementia as with any other mental health condition, though dementia has sometimes been thought of as different from other mental health conditions because it cannot be reversed.

Some confusion can be alleviated, some quality of living restored, by applying the lessons of “positive aging.”[3] And people with all forms of dementia can benefit from psychosocial interventions, which Appendix A to this position statement examines in detail and contrasts with the relative lack of success in developing drugs to address dementia and related conditions. With better research and treatment, people can realistically hope to maintain better cognitive and emotional health in later life. MHA will refer to “positive aging” and “aging well” rather than “recovery” in the remainder of this position statement.

MHA urges that the budget discussions of all levels of government recognize the emerging needs of older people with mental health and substance use conditions, including cognitive health as a part of mental health. Innovative programs will be required to maintain and increase wellness as the American population goes through dramatic demographic change, and, “there is no health without mental health.” This issue should emerge as a major focus of health care reform implementation under the Affordable Care Act, to contain costs and encourage wellness by promoting “aging well.”

The overarching goals should be:

  • to reduce isolation and enable older people with mental health or substance use problems to live where they prefer, generally in the community, as long as they can – to “age in place;”
  • to assure access to clinically appropriate, culturally and linguistically competent care in the community and in congregate living settings for people who need more help as they grow older;
  • to encourage people to age well by helping them to preserve their mental as well as general health and sense of vitality and fulfillment as they age;
  • to prioritize public funding for psychosocial research and programs directed at aging well;
  • to increase research into Alzheimer’s disease and other forms of dementia and especially the anxiety, depression and psychosis that sometimes accompany cognitive impairment; and
  • to use all available regulatory tools and “nudges” to encourage pharmaceutical industry, academic and public interest study of out-of-patent and “off-label” drugs that can alleviate suffering.

Background

The population of people over age 65 in the United States is projected to double between 2000 and 2030, from 35 million to 70 million.[4] While mental illness is not an inevitable part of aging, and older people actually experience fewer mental health conditions (excepting cognitive impairment) as they age, approximately 6.9% of people aged 65-74 experience “frequent mental distress,”[5] and many experience mental health and substance use conditions associated with loss of functional capacity even though a formal diagnosis may not be justified. Anxiety and depression and the psychotic symptoms of dementia in all its forms must be addressed for people to age well, and MHA envisions a supportive, integrated system of both psychosocial and medical care that encourages people to meet such challenges as they occur.

Older people with mental health problems are a diverse population including:

  • people with lifelong serious and disabling mental illnesses;
  • people with Alzheimer’s disease and other forms of dementia (often with co-occurring episodic anxiety, depression, and psychosis);
  • people with severe depression, anxiety, and emotional and behavioral problems that contribute to high rates of suicide, social isolation, and preventable institutionalization;
  • people with less severe disorders that nevertheless limit their ability to age well; and
  • people who abuse substances, primarily alcohol and pain medications, but increasingly including people with lifelong addictions and those who use illegal substances recreationally.

As stated by Deborah Padgett in the conclusion to her Handbook on Ethnicity, Aging, and Mental Health, aging need not be a time of “irreversible decline and loss,” and depression and emotional distress can be mastered. She concludes: “Declines usually associated with aging are quite malleable and influenced less by aging per se than by a host of psychosocial and lifestyle factors such as stress, diet, and exercise. Among the [most important] psychosocial factors associated with successful aging are sense of control and autonomy and social support."[6] So “positive aging” can bring about overall wellness for individuals, focused on their personal goals and current place of residence, social support system, and community. The primary method is by strengths-based therapies[7] that build the healthy habits that MHA refers to as “wellness.” These strengths and supports are critical to aging well.[8]

For the same reason, Padgett explodes the “double jeopardy” concept that has stigmatized “ethnic aging.” After accounting for the underreporting common in minority communities, Padgett concludes that mental health conditions are no more prevalent in Black and Hispanic elders.[9] In fact, she argues the contrary. Since, “adaptive [psychological, social and cultural strengths and] strategies formulated over a lifetime of struggle are keys to successful aging,”[10] elders of color who have coped with deprivation and stigma over their entire lives may have better mastered the skills required to cope with late life challenges.

Still, nearly half of people over age 65 with a recognized mental or substance use disorder have unmet needs for services.[11] Older adults with mental health or substance use conditions often do not seek specialty mental health care. They are more likely to visit their primary care provider– often with a physical complaint.[12] And though treatment can be an important component of aging well, misdiagnosis, especially by non-specialists, is a significant concern, as is overreliance on drugs rather than psycho-social treatment. The interaction among physical, emotional and behavioral conditions is complex in older people:

  • Psychological stress may lead to general health problems;
  • General health problems may lead to mental decompensation;
  • Coexisting mental and general health challenges and responses may interact; and
  • Social and psychosocial resources and medical and complementary treatments may affect all of the above.

Treatment works when older people are accurately diagnosed. But in older people, assessments of functional disabilities and prescriptions for concrete improvements in quality of life are more important than labels. By this definition, up to 80% of older people recover from depression with appropriate treatment.[13] But more research is needed on the unique mental health issues associated with Alzheimer’s disease and other forms of dementia to achieve equivalent results with cognitive impairment and its psychiatric symptoms.

The ramifications of lack of access, misdiagnosis, and poor treatment reach beyond the mental well-being of the individual. There are serious physical consequences of untreated mental illness. Older people with chronic medical conditions such as diabetes and heart disease and co-occurring depression are at increased risk for disability, premature mortality, and high health care costs. In addition, people with serious mental illness are at high risk for obesity, hypertension, diabetes, cardiac conditions, respiratory problems, and communicable diseases that contribute to a life expectancy many years less than that of the general population.

Older people also face inevitable life challenges with emotional consequences such as disability, retirement, loss of status, reduced physical and mental abilities, losses of family and friends, and the inevitability of death. Older people with mental health challenges face these challenges with diminished resources and have to work harder to age well.

Older people with mental health or substance use problems are not yet a public policy priority, and MHA is only beginning to tear down this silo by recognizing the extent to which cognitive health as an essential aspect of mental health. In addition, because their needs usually overlap the mental health, substance abuse, general health, and aging services systems, the mental health concerns of elders often fall between the cracks. Specialized mental health and substance use services have not secured the resources necessary to provide appropriate care and treatment for older people. The general shift in mental health policy towards evidence-based, individual-centered care, consumer empowerment and recovery has not been reflected in improved services for older people. The primary and institutional care services that are the main source of care and treatment for older people with mental illnesses and substance use disorders rarely identify the particular needs and interests of this group. There is a widespread failure to integrate the aging, mental health and substance use treatment systems. A literature review shows the greatest support for community-based, multidisciplinary, geriatric mental health treatment teams.[14] But little of that is happening, yet.

Effective Services for Older People.[15] Evidence-based health care should be the foundation for building exemplary care tailored to needs of our aging population. Evidence-based health care:

  • supports flexible and individualized care based on individuals’ unique needs, histories and other factors, and does not dictate “one-size-fits-all” treatment;
  • develops research that is widely disseminated and vetted by advocates and people in treatment as well as researchers;
  • develops research that appropriately represents all major cultural and linguistic groups so that group differences can be understood and addressed;
  • focuses on prevention and treatment of Alzheimer’s disease and other forms of dementia and of the entire range of related mental health symptoms;
  • emphasizes safety and quality of life as the overarching goals; and
  • supports informed decision-making and positive aging as the principal determinants of care.

A comprehensive service system should include:[16]

  • outreach services, including community education and training, prevention and early intervention efforts, and screening and early identification;
  • community-based, multidisciplinary, geriatric mental health treatment teams;
  • comprehensive home and community based services, including integration with primary care, case management, peer and consumer-run services, caregiver supports, crisis services and long-term care;
  • mental health promotion interventions that seek to improve the quality of life for older adults, not simply mitigate the negative effects of aging; and
  • policy and legislative changes that address the problems of workforce development, funding, research, coalition-building and integrated service systems.

Integration of care is the key:

The vast majority of older adults with a mental health or substance use disorder also have other chronic conditions. Thus, it is critical to integrate mental health and substance use with other health services including primary care, specialty care, home health care, and residential-community-based care. There are various models for integrating mental health and general health services including:

  • training primary care providers in mental health, co-locating health and mental health services, using integrated treatment teams of health and mental health professionals;
  • using care managers to follow up with consumers outside of the office;
  • establishing primary care centers that specialize in serving older adults with mental disabilities, establishing health satellites at mental health centers;
  • using peers, or people with similar lived experience, to provide support to individuals with health and mental health problems; and
  • using community-based, multidisciplinary, geriatric mental health treatment teams.

The “health home” and “accountable care organization” concepts embedded in the Affordable Care Act are the most recent federal initiatives promoting integration of care.[17] As of 2015, there were 744 ACOs, serving 7.8 million Medicare “lives.”[18]

The growth of ACOs slowed in 2014, and there are numerous barriers to sustaining these approaches, especially in the Medicare population, including:

  • Providers lack knowledge of the various models for integrating mental health, substance use and general health services;
  • Integration runs counter to the current service traditions. Providers tend to work independently rather than in collaboration;
  • Older people’s mental health needs are not usually integrated into their overall discharge plan when they leave inpatient treatment;
  • Cost can constrain options, as Medicare, Medicaid, and private insurance may not adequately reimburse for mental health and substance use services or collaborative care; and
  • Research has not adequately addressed the psychosocial and pharmacological needs of older people, especially people with psychiatric symptoms that are associated with cognitive impairment.

Older people with mental health or substance use problems also often receive services and supports through social service agencies specializing in aging services. These include senior centers, case management, adult day care, and adult protective services. Unfortunately, there is currently a lack of cross-system knowledge and collaboration. Professionals who work in the specialty mental health, substance abuse, general health, or aging systems typically do not know about the services available in other systems, making it difficult to find appropriate services for older people.

Workforce Development. The behavioral healthcare system is not ready for the elder boom, which is predicted to hit in full force as the baby boomers retire. The diminishing workforce trained in geriatric mental health issues is of particular concern. Although peer support has shown its worth with younger adults, it has yet to be widely adapted to older people in need of assistance and support. Research supporting the use of peer support with this population is needed, along with training and implementation of this new workforce. It is also imperative that training in geriatric mental health be expanded and incorporated into curricula for health care professional education, especially for physicians, nurses, psychiatrists, psychologists, social workers, mental health counselors, peer specialists, and rehabilitation specialists. Currently there are roughly 2,425 geriatric psychiatrists in the United States with an estimated current need for 4,400 and a future need for 8,840. In regards to geriatric social workers, there are only 6,000 nationwide with a current need for 32,600 and a future need for 65,480.[19]

The Dementia Dilemma. In addition to mental health conditions, older people suffer from Alzheimer’s disease and from the eight other “neurocognitive disorders” identified in the DSM according to their “medical causes,” though the more recent literature has cast some doubt on those distinctions. Older people also experience what the DSM calls “mild neurocognitive disorders,” lesser declines in mental acuity often referred to as “mild cognitive impairment,” which may range from absent-mindedness to serious loss of mental functioning. An excellent 2015 summary, written in plain language by Berkeley Wellness, a publication of the University of California, can be found at http://www.berkeleywellness.com/healthy-mind/memory/article/could-we-stop-alzheimers?s=EFA_151003_AA1&st=email&ap=ed

The defining characteristic of dementia is significant impairment in activities of daily living. Most often, the clinical formulation of dementia is linked primarily to cognition, although such intellectual changes are often associated with behavioral changes, ranging from irritability and agitation to psychosis with hallucinations and delusions. Early onset Alzheimer’s disease is more easily defined as a distinct disease, but late onset dementia is often a mixed pathology. Plaques and tangles are not unique to Alzheimer’s disease. The overlapping and labile symptoms and physiological markers of dementia are such that controversy continues over the capacity to distinguish Alzheimer’s disease, even with a PET scan or in an autopsy, from the other forms of dementia identified in the DSM: Huntington’s disease (a genetic disorder that is better identified through genetic testing), Parkinson’s disease, Lewy body disease,[20] frontotemporal degeneration, traumatic brain injury (identified from the injury rather than a brain scan), prion (“mad cow”) disease, HIV infection (identified by viral load tests), and vascular disease (atherosclerosis or “hardening of the arteries). Our diagnostic categories will surely evolve as we learn more.

This means that as people age, wellness matters more, not less, making activities like exercise, a good diet, reading, art, music, social interaction, study and service increasingly important even as the inertia of our aging bodies heads for the couch and the television set. Anyone who lives long enough will experience the struggles of cognitive aging, whether or not diagnosed with the dementia label. But the loss need not swallow up the person, no matter what the label, and effort can produce results.

Despite the fervent hope of Alzheimer’s advocates, there is no pill on the horizon that is likely to cure Alzheimer’s disease or any other form of dementia. At best, symptoms may be delayed and complications averted. Nor is Ginkgo biloba[21] or any other substance going to prevent the aging of the brain, though some people may be helped by a variety of interventions that should be more studied and better understood. But cognitive impairment can in fact be slowed by a supportive system of psychosocial care grounded in the logic of positive aging. The emerging issues in the treatment of dementia are addressed in Appendix A to this position statement.

A Better Future

This analysis brings us full circle. Although some hope is held out for new drug or genetic therapies, Appendix A shows that psychosocial and public health measures are more effective in treating dementia. As Peter Whitehouse concluded in a recent essay:

Psychosocial interventions such as caregiver education, support groups, arts interventions, and other community programs have been demonstrated to improve quality of life. No drugs have been demonstrated to do the same (George and Whitehouse, 2010, Whitehouse and George, 2014, Portacone, Berridge, Johns, and Schicktanz, 2013, D’Alton, Hunter, Whitehouse, Brayne, and George, 2014, Katz and Meller, 2013).[22]

Having a sense of purpose and a community network in which to manifest that purpose seems to be important for brain health, an important component of aging well. But positive aging starts with more basic work --

  • Stay Positive.
  • Get Physically Active.
  • Get Enough Sleep.
  • Eat Well.
  • Connect with Other People.
  • And Take Care of Your Spirit.

Call to Action

  • Aging well is everyone’s business. A positive aging agenda will require dramatic expansion of available services—including:access to appropriate housing and social supports;
    • a focus on quality of life and person-centered goals;
    • integration of care among the mental health, health, substance use, and aging services systems;
    • building a much larger clinically and culturally/linguistically competent workforce; and
    • increasing and re-inventing funding sources to develop a match between funding mechanisms and service needs.
  • Health care reform is a promising avenue for promoting positive aging. Aging well and specialized behavioral, cognitive and emotional health needs should be priorities in the care of older people under the Affordable Care Act and in any changes made to Medicare.
  • Affiliates are urged to adopt an aging well agenda for their communities, and promote it in partnership with others, since many services, especially housing, will need to be provided by local and state governments and nonprofit agencies.
  • Affiliates may act as catalysts to make elder cooperative and congregate care more available in their communities.
  • Research is urgently needed to understand the causes of Alzheimer’s disease and other dementias and how to prevent and treat both the dementia itself and the depression, psychosis and anxiety that often accompanies it. Affiliates should encourage the development of community-based psychosocial programs to meet these emerging needs.
  • The federal, state and local governments and non-profit agencies and foundations should fund demonstration projects to explore new psychosocial treatments for dementia and co-occurring conditions and to improve the evidence base for those that exist. Psychosocial treatments have been shown to be more effective than drug therapies and should be promoted and used more extensively in the absence of approved drug therapies and in recognition of the substantial adverse side effects of the off-label drug therapies now being used.
  • MHA urges much more research and public education concerning cholinesterase inhibiters, glutamate antagonists, antidepressants, antipsychotics and anxiolytics for use in dealing with dementia and its symptoms and co-occurring conditions. See Appendix A for more details.
  • If additional authority is needed for the FDA to insist on full disclosure and additional studies of drugs being marketed and used off-label as frequently as are antipsychotics and benzodiazepines, MHA strongly supports congressional action to grant such authority. In addition, the FDA should use the full range of enforcement incentives and “nudges” that it can devise to get these drugs properly evaluated and controlled. Academic researchers and public interest organizations like the Cochrane Collaboration should be recruited to help.
  • MHA urges the pharmaceutical industry to help build and publicize an evidence base to help people with dementia who lack access to on-label medications to treat psychotic symptoms and anxiety.

APPENDIX A

Treatment of Cognitive Aging and Dementia

Promoting Wellness

Validation Therapy

Nursing Protocols

Other Psychosocial Initiatives

Drug Therapies for Dementia (Cholinesterase Inhibitors)

Drug Therapies for Depression, Anxiety and Psychosis Related to Dementia

Antipsychotics

Emphasize Non-drug Interventions to treat Psychosis

Comparative Effectiveness and Comparative Side Effect Prevalence Analysis Required

Anxiolytics

In a 2015 study of “Cognitive Aging,” the IOM counseled that “cognitive aging is a natural process that can have both positive and negative effects on cognitive function in older adults—effects that vary widely among individuals.” It identifies and promotes actions that individuals, organizations, communities, and society can take to help older adults maintain and improve their cognitive health. The IOM assesses the state of knowledge about cognitive aging, including definitions and terminology, epidemiology and surveillance, prevention and intervention, education of health professionals, and public awareness and education. It is a good place to start in understanding what we now know about the aging brain.[23]

Similarly, researcher/clinicians like the once-controversial Peter Whitehouse have begun treating dementia and cognitive impairment on a continuum, and used a positive aging model as a way to respond.[24] Quality of life and the interventions to preserve and restore it differ by individual more than by diagnosis. The most demonstrated improvement is with psychosocial, rehabilitative approaches. In this view, “dysfunction and disability are more important than precise diagnosis; quality of life trumps cognitive enhancement; community engagement is key; and population health perspectives gain influence over individual health.”[25]

With brains, as with so much else in life, “you use it or you lose it.” Those most involved in life are the most likely to stay involved and stay well. “Neurodegenerative conditions do not ‘claim’ older people, nor do they dominate them or degrade their humanity. They simply alter how they live their lives.”[26] Effective prevention and appropriate treatment of all kinds of dementia may be the greatest public health challenge posed by the aging of the boomers.

Promoting Wellness

As with any mental health condition, both cognitive aging and dementia are best addressed early and often. The IOM recommends that individuals should:

  • Be physically active.
  • Reduce and manage cardiovascular disease risk factors (including hypertension, diabetes, and smoking).
  • Regularly discuss and review health conditions and medications that might influence cognitive health with a health care professional…. A number of medications can have a negative effect on cognitive function when used alone or in combination with other medications. The effects can be temporary or long-term.
  • Take additional actions that may promote cognitive health, including [remaining] socially and intellectually engaged, and engage[ing] in lifelong learning.
  • Get adequate sleep and receive treatment for sleep disorders if needed. [and]
  • Be aware of the potential for financial fraud and abuse, impaired driving skills, and poor consumer decision making, and make health, finance, and consumer decisions based on reliable evidence from trusted sources.

In 2009, MHA launched a website (no longer active) called “Live Your Life Well,” intended to promote mental wellness through ten straightforward steps:

  • Connect with Others. People who feel connected are happier and healthier--and may even live longer.
  • Stay Positive. People who regularly focus on the positive in their lives are less upset by painful memories.
  • Get Physically Active. Exercise can help relieve insomnia and reduce depression, and reduce chronic disease.
  • Help Others. People who consistently help others experience less depression, greater calm and fewer pains.
  • Get Enough Sleep. Not getting enough rest increases risks of weight gain, accidents, reduced memory and heart problems.
  • Create Joy and Satisfaction. Positive emotions can boost your ability to bounce back from stress.
  • Eat Well. Eating healthy food and regular meals can increase your energy, lower the risk of developing certain diseases and influence your mood.
  • Take Care of Your Spirit. People who have strong spiritual lives may be healthier and live longer. Spirituality seems to cut the stress that can contribute to disease. Spirituality does not necessarily involve religion. Art and music are forms of spirituality.
  • Deal Better with Hard Times. People who can tackle problems or get support in a tough situation tend to feel less depressed. [and]
  • Get Professional Help if You Need It. More than 80 percent of people who are treated for depression improve.

Validation Therapy

“Validation therapy” is a prototype of the psychosocial approaches now being developed for older people with cognitive impairments and dementia. Social worker Naomi Feil has written extensively and maintains a consultancy[27] promoting validation therapy. The basic principle of the therapy is the reciprocated communication of respect, which communicates that the other's opinions and feelings are heard, understood, acknowledged, and (regardless whether or not the listener actually agrees with the content) that the person is being treated with genuine respect, rather than being marginalized or dismissed.

Validation therapy uses specific techniques, and it has attracted criticism from researchers who dispute the evidence, which is generalized rather than specific, and thus difficult to synthesize in a meta-analysis. There is not yet enough rigorous evidence proving the efficacy of validation therapy, but it is a promising practice, harmless and an important line of defense as caregivers confront the anxiety, depression and psychosis that often come with cognitive impairment.

Nursing Protocols

Nursing protocols appropriately emphasize psychosocial interventions. Thus, the AHRQ National Guideline Clearinghouse[28] recommends:

The Progressively Lowered Stress Threshold (PLST) provides a framework for the nursing care of individuals with dementia.

  • Monitor the effectiveness and potential side effects of medications given to improve cognitive function or delay cognitive decline.
  • Provide appropriate cognitive-enhancement techniques and social engagement.
  • Ensure adequate rest, sleep, fluid, nutrition, elimination, pain control, and comfort measures.
  • Avoid the use of physical and pharmacologic restraints.
  • Maximize functional capacity: maintain mobility and encourage independence as long as possible; provide graded assistance as needed with ADLs and IADLs; provide scheduled toileting and prompted voiding to reduce urinary incontinence; encourage an exercise routine that expends energy and promotes fatigue at bedtime; and establish bedtime routine and rituals.
  • Address behavioral issues: identify environmental triggers, medical conditions, caregiver–patient conflict that may be causing the behavior; define the target symptom (i.e., agitation, aggression, wandering) and pharmacological (psychotropics) and nonpharmacological (manage affect, limit stimuli, respect space, distract, redirect) approaches; provide reassurance; and refer to appropriate mental health care professionals as indicated.
  • Ensure a therapeutic and safe environment: provide an environment that is modestly stimulating, avoiding overstimulation that can cause agitation and increase confusion and under-stimulation that can cause sensory deprivation and withdrawal. Utilize patient identifiers (name tags), medic alert systems and bracelets, locks, and wander guard. Eliminate any environmental hazards and modify the environment to enhance safety. Provide environmental cues or sensory aids that facilitate cognition, and maintain consistency in caregivers and approaches.
  • Encourage and support advance-care planning: explain trajectory of progressive dementia, treatment options, and advance directives.
  • Provide appropriate end-of-life care in terminal phase: provide comfort measures including adequate pain management; weigh the benefits/risks of the use of aggressive treatment (e.g., tube feeding, antibiotic therapy).
  • Provide caregiver education and support: respect family systems/dynamics and avoid making judgments; encourage open dialogue, emphasize the patient's residual strengths; provide access to experienced professionals; and teach caregivers the skills of caregiving.
  • Integrate community resources into the plan of care to meet the needs for patient and caregiver information; identify and facilitate both formal (e.g., Alzheimer's associations, respite care, specialized long-term care) and informal (e.g., churches, neighbors, extended family/friends) support systems.

Other Psychosocial Initiatives

Many exercise, educational, hobby, craft and other initiatives have been developed to promote positive aging, and senior centers and congregate care facilities all provide some level of stimulation and wellness education. A particularly interesting model is the Intergenerational School, a three-campus charter school in Cleveland, Ohio that uses elders as an integral part of its staff and curriculum. The Intergenerational School has been nationally recognized for its innovative, intergenerational approach to learning.[29]

Brain games are a more recent innovation, using computer software to stimulate cognition. But a 2014 Stanford consensus report[30] largely debunked the currently-available products:

  • Many claims are “exaggerated and misleading” and exploit the anxiety of healthy older adults worried about memory loss. There’s no convincing evidence that any brain training programs will improve general cognitive abilities or help prevent or treat dementia.
  • The companies often boast that their programs are designed by famous scientists and supported by solid research, but most of the studies they cite are small, short, and poorly designed, and many are conducted by researchers with financial interests in the products. The findings are often only tangentially related to the advertised claims. What’s more, it’s unclear whether any improvements in skills practiced in brain games would persist until even the next day or carry over to other cognitive tasks and daily living.
  • The best brain-health advice, based largely on observational find­ings, is to lead a physically active, intellectually challenging, and socially engaged life, the authors wisely concluded. In particular, much research shows that physical exercise is a moderately effective way to maintain and even improve brain fitness. As the report pointed out, “If an hour spent doing solo software drills is an hour not spent hiking, learning Italian, making a new recipe, or playing with your grandchil­dren, it may not be worth it.”

Research is desperately needed to guide essential psychosocial treatment, but more importantly, MHA calls for innovation, including increased use of peer counselling to increase stimulation and decrease anxiety, technological applications to supplement a failing memory, interactive, voice-activated programs to minimize data entry issues, sophisticated monitoring and GPS location programs to keep people oriented in space and time, and various kinds of household robots to allow people to live in their own hopes with minimal help. Over time, and with a focus on peer support, whole communities can be redesigned to promote aging well.

Drug Therapies for Dementia (Cholinesterase Inhibitors)

Unfortunately, current drug therapies for Alzheimer’s disease and other dementias are not very effective and, despite FDA approval, are controversial for that reason. Drug therapies to deal with the anxiety and psychosis that often accompany the cognitive symptoms of dementia are off-label, little studied, and thus even more controversial. Dementia treatment is not an issue that MHA has addressed in the past, but the serious deficiencies of existing prescribing practices demands scrutiny. The next sections of this position statement will provide guidance for the present and advocacy for the future, with the caveat that psychosocial interventions should both precede and accompany drug therapy, and that while no cure is in sight, MHA holds out hope that some of the many current research initiatives will prove fruitful.

There is no magic pill to prevent the aging of the brain or the other causes of dementia. But the U.S. Food and Drug Administration (FDA) has approved three cholinesterase inhibitors -- donepezil (Aricept), rivastigmine (Exelon) and galantamine (Razadyne) -- and one glutamate antagonist -- memantine (Namenda) — to treat the cognitive symptoms (memory loss, confusion, and problems with thinking and reasoning) of Alzheimer's disease.[31] Doctors sometimes prescribe both types of medications together. Some doctors also prescribe high doses of vitamin E for Alzheimer's disease, although that that is becoming less common.[32]

Although current medications cannot cure Alzheimer’s or stop it from progressing, they may help lessen symptoms, such as memory loss and confusion, but only for a limited time. As stated by Consumer Reports:[33]

“…[A]fter six months on the drugs, most of the patients show no improvement in mental functioning, based on their doctors’ assessments and tests of basic thinking skills. Among the few who do benefit, the improvement is typically slight. The available studies have not shown that the drugs help achieve what we would consider major goals of dementia treatment, prolonging people’s ability to live independently or improving quality of life for either patients or caregivers,” [Consumer Reports reported].

Even a small benefit or chance of improvement might be worth it if Alzheimer’s drugs were risk free. But they are not. They can cause side effects such as insomnia, nausea, muscle cramps, diarrhea, and reduced appetite, all of which can be troublesome for people with dementia. Rarely, the drugs may cause more serious side effects such as internal bleeding and a slowed heart rate that could be potentially dangerous.”

Cholinesterase inhibiters are widely endorsed and used. However, they are expensive, and the effect is modest at best. There is some evidence of permanent worsening of symptoms upon discontinuation of treatment,[34] so once started, it may be hard to stop until late in the course of the disease. But there are inadequate data to substantiate this concern. The Cochrane Dementia and Cognitive Improvement Group’s[35] 2006 review concluded:

The results of ten randomized, double blind, placebo controlled trials demonstrate that treatment for six months, with donepezil, galantamine or rivastigmine at the recommended dose for people with mild, moderate or severe dementia due to Alzheimer's disease produced improvements in cognitive function, on average -2.7 points (95%CI -3.0 to -2.3, p<0.00001), in the midrange of the 70 point ADAS-Cog Scale. Study clinicians rated global clinical state more positively in treated patients. Benefits of treatment were also seen on measures of activities of daily living and behavior. None of these treatment effects are large.

The effects are similar for patients with severe dementia, although there is very little evidence, from only two trials.

A 2012 Cochrane review focused on Parkinson’s disease and dementia with Lewy bodies was more positive:

The clinical features of dementia with Lewy bodies (DLB) and Parkinson's disease with dementia (PDD) have much in common. As patients with DLB and PDD have particularly severe deficits in cortical levels of the neurotransmitter acetylcholine, blocking its breakdown using a group of chemicals known as cholinesterase inhibitors may lead to clinical improvement. Six trials showed a statistically significant improvement in global assessment, cognitive function, behavioral disturbance and activities of daily living rating scales in PDD and cognitive impairment in Parkinson's disease (CIND-PD) patients treated with cholinesterase inhibitors.

However, the effect is still modest. Finally, the conclusions of a 2012 Cochrane review of studies of the use of cholinesterase for mild cognitive impairment were quite negative:

There is very little evidence that cholinesterase inhibitors affect progression to dementia or cognitive test scores in mild cognitive impairment. This weak evidence is overwhelmed by the increased risk of adverse events, particularly gastrointestinal. Cholinesterase inhibitors should not be recommended for mild cognitive impairment.

Until a political decision was made to make cholinesterase inhibiters generally available in the U.K., the U.K. National Health Service attempted to restrict reimbursement,[36] and experts like Peter Whitehouse[37] continue the dialogue in the United States. However, on balance, Whitehouse agrees that, in the current state of knowledge, he would be willing to prescribe cholinesterase inhibitors for dementia, because the effect, though small and by no means assured, could still be significant for the individual. People in treatment need to understand this background to be able to decide whether or not to start on dementia drugs in light of the evidence, which is positive only for Parkinson’s and Lewy body dementia, demonstrates only modest relief of symptoms at best, does not demonstrate any slowing of the disease process, discourages use in mild cognitive impairment, and indicates a risk both in using and in discontinuing the medication.

The truth is that we still know very little about the pathology of dementia, and the increasing focus on Alzheimer’s disease, while helpful in focusing attention on the riddle of dementia, obscures the individual factors that make each diagnosis unique:

Perhaps everyone’s Alzheimer’s condition or dementia is unique to them because different individual processes are involved throughout the life-course, including factors like head injuries, diet, alcohol consumption, and a panoply of social determinants of health, including air and water quality. Moreover, in the last several decades increasing overlaps between aging and dementia and among types of dementias have become more apparent. Neuronal loss, plaques, and tangles all can occur in individuals who do not have a clinically apparent dementia. Moreover, these features can occur in other conditions such as Parkinson’s and frontal lobe dementia. Our ability to differentiate these overlapping conditions from each other, much less from processes associated with aging, remain rudimentary. Even the allegedly clear-cut distinction between vascular disease and neurodegenerative disease is getting muddier the more we look at risk factors and biological markers.[38]

This aptly describes a scientific tangle every bit as complicated as the tangles associated with dementia. More research is clearly necessary and may someday help American society to cope with what is likely to become an epidemic as our population ages. The key is to pursue research into psychosocial as well as pharmacological interventions.[39]

Drug Therapies for Depression, Anxiety and Psychosis Related to Dementia

Causes of and treatments for Alzheimer’s disease and other forms of dementia are riddles that future research must address. But there are critical, practical issues that must be addressed right now in managing the psychiatric symptoms of cognitive impairment, and it is an indictment of our drug regulatory system that they are only now being addressed at all.

People with dementia experience anguish and anxiety from life crises and loss of mental capacities and often have psychotic and depressive symptoms as well, and the agitation, depression and psychotic features impair quality of life, perhaps even more than the cognitive symptoms in many people. For example, many people with dementia do not recognize where they are, even in their own home, or who is taking care of them, and feel unsafe, anxious and depressed. In the absence of data specific to older people or people with dementia, these symptoms have been treated with medications approved for anxiety (principally benzodiazepines), depression, and psychosis. Antidepressants are effective in treating co-occurring depression and have not yet been controversial,[40] though testing in elderly populations has lagged. The widespread off-label use of antipsychotics has raised the greatest problems. However, the use of benzodiazepines for anxiety is being called into question as well. They are effective but potentially addictive and definitely exacerbate delusions. Thus, their use should at least be minimized.

Antipsychotics

In the absence of U.S. Food and Drug Administration (FDA) guidance, physicians have used off-label antipsychotics to treat psychotic symptoms of dementia. As of 2010, one-quarter of nursing-home residents had used antipsychotics.[41] The U.S. General Accounting Office (GAO) found that by 2012, the proportion had risen to one third.[42] MHA agrees with the GAO that these percentages are an indictment of the long-term care industry.

The available scientific evidence is weak, as pointed out in a 2005 JAMA review:

  • For typical antipsychotics,…[g]enerally, no difference among specific agents was found, efficacy was small at best, and adverse effects were common. Six RCTs [randomized controlled trials] with atypical antipsychotics were included; results showed modest, statistically significant efficacy of olanzapine and risperidone, with minimal adverse effects at lower doses. Atypical antipsychotics are associated with an increased risk of stroke. There have been no RCTs designed to directly compare the efficacy of typical and atypical antipsychotics. Five trials of antidepressants were included; results showed no efficacy for treating neuropsychiatric symptoms other than depression, with the exception of one study of citalopram. For mood stabilizers, three RCTs investigating valproate showed no efficacy. Two small RCTs of carbamazepine had conflicting results. Two meta-analyses and six RCTs of cholinesterase inhibitors generally showed small, although statistically significant, efficacy. Two RCTs of memantine also had conflicting results for treatment of neuropsychiatric symptoms.

Pharmacological therapies are not particularly effective for management of neuropsychiatric symptoms of dementia.[43]

NAMI summarized the evidence on Treatment of Behavioral and Psychological Symptoms of Dementia in 2014 as follows:

  • Atypical antipsychotics (6 RCTs) – Modest but statistically significant effects – Few adverse events at lower doses BUT: ~1.6-1.7 fold increase in mortality in active treatment over placebo – Rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Deaths due to heart related events (e.g., heart failure, sudden death) or infections (mostly pneumonia), cerebrovascular adverse events, hyperglycemia and diabetes mellitus.
  • Typical antipsychotics (2 RCTs) – Minimal efficacy, frequent adverse events (may be severe) – [Associated with significantly higher adjusted risk of death relative to atypical antipsychotics -- MHA contests this assertion. Both typical and atypical antipsychotics are associated with significantly higher adjusted risk of death.[44] ]
  • Mood stabilizers/antidepressants (5 RCTs) – No efficacy on neuropsychiatric symptoms except depression.
  • Antiepilepsy drugs (5 RCTs) – No efficacy with valproate; conflicting results with carbamazepine.
  • Cholinesterase Inhibitors (6 RCTs) – Minimal effect/conflicting results; statistically significant in 2 RCTs.
  • Memantine (2 RCTs) – Conflicting results.[45]

Few studies of these drugs have been done in older people and in dementia of various types. Antipsychotics are widely used even though they increase the risk of death in elders. As has been documented in a recent (2015) serialized book by Steven Brill, published by the Huffington Post,[46] drug companies have promoted off-label use of antipsychotics without seeking FDA approval for their claims.

This situation requires a little explanation. The FDA reviews drugs for efficacy and safety and approves drugs for specific conditions. These are the labeled indications. The FDA does not regulate or monitor physicians, who are governed only by state licensure and civil malpractice. Clinicians with appropriate state licensure may prescribe any drug approved by the FDA for any purpose for any other condition that they believe warrants using the drug, without regard to the FDA label. This is called “off-label use.” In recent years, drug companies have been more assertive in marketing drugs. They have sometimes promoted off-label use, as illustrated by the following cautionary tale:

Despite the lack of FDA approval of its “second generation” “atypical” antipsychotic Risperdal (risperidone) for use in older people or in people with dementia, and a 2005 express FDA “black box” WARNING -- Warning: Increased mortality in elderly patients with dementia-related psychosis – the manufacturer thereafter aggressively marketed risperidone “for simple symptoms of dementia or restlessness.”[47] In a plea agreement resolving these charges, it conceded that it illegally promoted Risperdal to health care providers “for treatment of psychotic symptoms and associated behavioral disturbances exhibited by elderly, non-schizophrenic dementia patients.”[48]

The dilemma for a family or a person in treatment is that there is no pharmaceutical treatment approved by the FDA for treatment of psychotic symptoms and associated behavioral disturbances exhibited by elderly people with dementia who do not have schizophrenia, even though the DSM 5 expressly states that antipsychotics are used for that purpose. Thus, if available psychosocial care is inadequate to deal with the symptoms, when the family or the care facility has run out of options, a typical or atypical antipsychotic will be prescribed off-label. Based on an unscientific sample collected by MHA, hospice programs often prescribe haloperidol (Haldol), an older and cheaper typical antipsychotic, while psychiatrists generally use atypical antipsychotics. But all use extremely low doses, and clinicians and care workers alike claim that the drugs are effective in a significant number of patients, based on their experience.

Yes, the evidence is weak, and there is a significant risk of stroke and other side effects, but if available psychosocial approaches fail, antipsychotic drugs will be used to deal with psychotic symptoms, especially when needed to preserve the safety of the staff and other people in treatment, and to avoid the use of seclusion and restraints. Why then is someone not busy studying risperidone and other anti-psychotics and working on comparisons and improvements right now?

The general answer is that private funding now dictates the direction of most research. “When looking at the numbers, I see an imbalance,” said Stephan Ehrhardt, an associate professor in the Johns Hopkins Bloomberg School of Public Health’s Department of Epidemiology, in a 2015 study. “Industry doesn’t fund trials most important for public health because they have no incentive to do that.”[49]

This trend has emerged as the budget for the National Institutes of Health— the primary source of government funding for clinical trials — has been slashed 24 percent since 2006 amid belt-tightening in Washington. The drug and medical device industry now funds six times more clinical trials than the federal government, according to the Johns Hopkins University researchers. That means companies with financial interests in the studies now have more control over what doctors and patients learn about new treatments. And pharmaceutical companies are unlikely to address the use of antipsychotics in dementia care:

First, because most antipsychotics are now out-of-patent, and there is little profit to be made.

Second, because there are significant ethical issues whenever people have complicated medical conditions, as the elderly always do, and whenever competency is in question, as it is in anyone with dementia.

And third, because the risk/benefit equation is skewed, and the public policy that favors finding a reliable drug and demonstrating its reliability to treat the psychiatric symptoms of dementia has been ignored in prioritizing punishing manufacturers for promoting off-label uses.

MHA believes that a more significant additional sanction would be to require the manufacturer to conduct and disclose studies to back up its claim. If additional authority is needed for the FDA to insist on full disclosure and additional studies of drugs being marketed and used off-label as frequently as are antipsychotics, MHA strongly supports congressional action to grant such authority. In addition, the FDA should use the full range of enforcement incentives and “nudges” that it can devise to get these drugs properly evaluated and controlled. Academic researchers and public interest organizations like the Cochrane Collaboration should be recruited to help. And NIH funding should be increased to focus more research on these drugs and others with major public health implications.

Finally, MHA urges the pharmaceutical industry, in the public interest, to help build an evidence base of published and unpublished studies that it has conducted of the use of anti-psychotics to treat psychiatric conditions associated with dementia. Whenever possible, the federal government should insist, in the interest of science, that ALL such studies be made available to the public.

Can physical activity improve the mental health of older adults?

This article has been cited by other articles in PMC.

Abstract

The world population is aging rapidly. Whilst this dramatic demographic change is a desirable and welcome phenomenon, particularly in view of people's increasing longevity, it's social, financial and health consequences can not be ignored. In addition to an increase of many age related physical illnesses, this demographic change will also lead to an increase of a number of mental health problems in older adults and in particular of dementia and depression. Therefore, any health promotion approach that could facilitate introduction of effective primary, secondary and even tertiary prevention strategies in old age psychiatry would be of significant importance. This paper explores physical activity as one of possible health promotion strategies and evaluates the existing evidence that supports its positive effect on cognitive impairment and depression in later life.

Introduction

The world's population is aging at a rapid pace. In Australia, for example, in 2001 more than 2.3 million persons were above the age of 65, which is 12.4% of the total population. It is expected that this number will increase to 6 million over the next 50 years thus amounting to 24.2% of the total population [1].

Whilst increasing longevity is a positive development, it also leads to an increase in age-related diseases and disabilities with all its social and financial implications for society. Somatic disorders such as cardiovascular diseases, cancer, movement disorders, osteoporosis, osteoarthritis and special sensory deficits are all highly prevalent in later life. Mental disorders are also frequent in later life (affecting approximately 20% of old people), with dementia and depression being the most prevalent conditions in this age group [2]. Moreover, dementia and depression are the leading causes of years of life lost due to disability in Australia [3]. Currently, more than 25 million people worldwide have dementia, with Alzheimer's Disease (AD) being the most frequent cause of dementia in Western societies [4].

There is an urgent need to focus research on the development and evaluation of effective preventative strategies, such as those successfully introduced to decrease the incidence of coronary heart disease, stroke and some cancers. Delaying the clinical onset of AD by two years would reduce the total number of AD cases by approximately 600,000 in the USA alone [5]. Physical activity (PA) is often seen as an intervention that has the potential of decreasing the burden associated with depression and cognitive impairment in later life and this paper represents a critical review of the evidence that supports such an association.

Aging and physical activity

Sedentary lifestyle is becoming increasingly common at all ages [6]. A recent survey found that 62% of Australians were sufficiently active to enjoy the health benefits associated with PA in 1997 but, worryingly, this number declined to 57% in 1999 [7]. Ageing is associated with progressive decline in activity levels, which are also influenced by education, gender, ethnicity and income [8]. Older adults are more likely to engage in PA of lower intensity, such as walking, gardening, riding a bicycle, or playing golf rather than running, doing aerobics or team sports [9]. For example, the most popular types of physical activity amongst Western Australians aged 60 years or over were walking for recreation (60%), gardening (48%) and playing golf (15%) [10].

Can physical activity protect or improve health in older adults?

Regular PA, including in later life, can reduce morbidity and mortality, postpone disability and prolong independent living [11], which can potentially counterbalance some negative effects of aging [12]. Suggested effects of regular PA include the preservation of muscle mass, prevention of sarcopenia and reduction of the age-related decrease of metabolic rate [13]. There is good evidence that being physically active improves cardiovascular outcomes, reduces the risk of diabetes and some types of cancer (especially breast cancer), assists in the prevention of falls, and maintains peak bone mass [14].

Can physical activity influence cognitive function?

The relationship between PA and cognitive function remains unclear. Regarding physiological effects, one hypothesis is that PA can counter age-related decline in cardiovascular function associated with brain hypoxia and consequent cognitive decline.

Dishman suggested that increased oxygenation of the brain may stimulate and protect the central nervous system [15]. Only a handful of studies have systematically investigated the association between PA and cognitive function. Stewart et al. reported that physically active subjects were 50% less likely to present with cognitive impairment (OR = 0.48; 95% CI= 0.23–1.02) [16]. Schuit et al. (2001) also found that adults who exercised at least 30 min/day had higher MMSE scores than older adults who did not (p < 0.05) [17]. This same group showed that carriers of the ε4 allele of the apolipoprotein E (APOE), a genetic risk factor for AD, have a 13.7-fold increase in the risk of cognitive decline (95% CI: 4.2–45.5) if they perform less than one hour of PA per day when compared to non-ε4 carriers who are active. This finding suggests that PA may contribute to modify the deleterious effect on cognition of the APOE ε4 genotype.

Yaffe et al. stratified their subjects according to a self-report questionnaire that provided an estimate of the number of kilocalories (kcal) expended per week or city-blocks ( = 160 m) walked per week [18]. Women in the highest quartile of activity had an OR of 0.66 (95% CI: 0.54–0.82) of experiencing significant cognitive decline during 6–8 years follow-up when compared to women in the lowest quartile of physical activity. More importantly, the findings of three independent follow-up studies indicate that PA may reduce the risk of dementia in later life [19-21]. Laurin et al. showed, in nested case-control study with 4,615 community-dwellers participating in the Canadian Study of Health and Aging, that older subjects engaging in moderate to high levels of PA were less likely to develop cognitive impairment (OR = 0.57, CI: 0.46–0.70) or dementia (OR = 0.58, 95% CI: 0.45–0.76). Older women performing PA of greater intensity than walking more than 3 times a week seemed to benefit the most from the protective effect of PA against AD [21].

Randomized control trials looking at the effects of PA on cognition are rare, but the results of two studies are of interest. Emery et al. observed that subjects suffering from chronic airway disease who walked, as exercise, for 10 weeks had significantly better word fluency than non-active controls [22]. Molloy et al. reported similar findings in an intervention trial investigating older female outpatients after three months of a 45-minute exercise program [23]. Most of the studies mentioned above recruited individuals who were cognitively normal at the time of entry into the study. These studies had relatively small sample sizes and the measures of cognitive function (such as the MMSE) used were rather crude.

Can patients with dementia benefit from physical activity?

Trials with PA in older adults who are already suffering from cognitive decline or dementia are rare [24]. This is surprising, as regular physical activity is recommended for patients with dementia not only to support physical health, but also to improve quality of life and behavioral and psychological symptoms (BPSD). BPSD occur in most patients with AD at some stage of the course of the illness and are especially stressful to carers, as well as the patient. One study found that regular physical activity can prevent weight loss in AD [25] whereas another [26] reported that patients with mild to severe AD benefited from a 7-week PA program in regards to the risk of falls, BPSD, cognitive function and nutritional status.

Scarmeas et al. has also reported that higher levels of PA amongst patients with AD is inversely correlated with cerebral blood flow to the temporal and parietal lobes [27]. This was interpreted as being an indication that physical active patients have a higher brain reserve.

In addition, postmortem examination has shown that patients who were physically active present a significantly larger burden of disease than sedentary patients who have a similar degree of cognitive impairment. This finding supports the brain reserve hypothesis and suggests that regular PA delays the clinical progression of AD by counteracting the effects of AD-related brain pathology. Teri et al. investigated, in a randomized clinical trial, whether a home-based exercise program would reduce functional dependence and delay the institutionalization of 153 community-dwelling subjects with AD [28]. Patients and their carers were randomized to an exercise plus behavioral management technique group (intervention) or to a "routine medical care" (control) group. The intervention was carried out in the homes of patients and lasted 3 months. The exercise component was a mixture of endurance activities, strength training, balance, and flexibility training and altogether 12 hours of exercise in 30 min intervals were performed.

The patients in the intervention group were, at 3 months, more physically active and had improved scores for physical functioning and depression compared to the patients of the control group. Even after 2 years, the intervention group had significantly better physical functioning scores. They also were less likely to be institutionalized because of behavioral problems than controls (19% versus 50%). Although this study produced valuable new information, it remains unclear to what extent the effect was caused by exercise, by the training of the carers, or by a combination of both interventions.

Can physical activity influence mood in older adults?

Penninx et al. reported a significant reduction of depressive symptoms amongst their 439 older adults participating in an 18-month walking program, hinting at the possible antidepressant effect of physical activity [29]. Such an effect is supported by a randomized clinical trial reported by Blumenthal et al. [30]. They recruited 156 people aged 50 to 77 years who met criteria for the diagnosis of a major depressive episode according to DSM-IV. Subjects were randomized to treatment with sertraline (50 to 200 mg), exercise, or a combination of both. Subjects randomized to exercise attended 3 supervised sessions of physical activity per week for 16 consecutive weeks (walking and jogging). All three forms of treatment were associated with a significant reduction of depression scores, and there was no significant difference in treatment response between the groups. There is also encouraging evidence that the positive effect of physical activity on mood may persist over time. Singh et al. studied a sample of 29 subjects aged 60 years and over who were randomized to a 10-week program of supervised exercise (n = 15) or education, and were later followed-up for another 20 weeks [31]. They found a significantly greater decline of depression scores amongst subjects in the exercise group after 20 weeks and 26 months. In addition, Babyak et al. showed that subjects with a depressive disorder who exercise are less likely to relapse after 10 months, particularly if they remain physically active during the follow-up period [32]. Finally, the results from the Almada County Study showed that physical activity was associated with decreased odds of prevalent (OR-0.90, 95% CI = 0.79–1.01) as well as incident depression over 5 years (OR = 0.83, 95% CI = 0.73–0.96) in a community-dwelling sample of 1947 adults aged 50 to 94 years [33].

Physical activity and quality of life in older adults

The large body of research in this area clearly demonstrates that a major aim of PA programs is not just decreasing mortality, but also decreasing morbidity i.e. 'adding life to years' and not just 'years to life'. Spirduso and Cronin have recently shown, in a detailed review of cross-sectional and prospective studies, that PA is consistently associated with improved well being and better quality of life in later life [34]. They also concluded that long-term PA delays disability and maintains independent living. In addition, older adults who expend larger amounts of energy daily (walking, gardening and exercise) are more likely to have optimal function in their activities of daily living (ADL).

Physical activity recommendations for older adults

The National Heart Foundation of Australia recommends 30 minutes of moderate intensity PA (activity that is energetic, but at a level at which a conversation can be maintained) on most or all days of the week to improve cardiovascular health. They also suggest that "the total amount of PA seems to be more important than the intensity, so that lower intensity daily activity may confer benefits that are similar to higher intensity activity on fewer days of the week". This was confirmed by the results of randomized trials that included lifestyle PA as well as structured exercise programs [35]. The Center for Disease Control and Prevention (CDC) calls for increased level of activity by incorporating any activity of at least moderate intensity into the day. For older adults, the daily accumulation of PA (stair climbing, gardening, brisk walking, or housework) in intermittent short bouts may be sufficient to achieve the recommended 200 kcal/day [36]. Suggested types of PA for older adults include moderate cardiovascular training with walking being the most popular, strength training, aerobic and balance and flexibility training. Balance training has been shown to reduce falls (Judge et al, 2003). Even more so than for younger adults, older people should be screened for illnesses, such as heart disease, before they start a PA program.

Can older adults be motivated to participate in physical activity?

More than any other age group, older adults are seeking health information and are willing to make behavioral changes to maintain their health and independence [37]. Unfavorable perceptions of one's own health are associated with lower engagement in PA, whereas perceived enjoyment and satisfaction are possible predictors of more frequent PA in men and women of all ages [38]. This suggests that psychosocial rather than biomedical variables may influence continued participation in exercise programs. In addition, older adults are more compliant with interventions that allow them to perform their PA of choice on their own, in an environment where they feel safe and competent, and where competition is not an issue [39].

An expert panel identified important determinants for exercise compliance: biomedical status, past exercise participation, and educational level [40]. Van der Bij et al. concluded, in a review of PA interventions for older adults, that in the short-term (< 1 year) home and group-based interventions are equally successful in achieving high participation rates (84–90%), although these rates tend to decline with time (≥ 1 year) [41]. PA intervention trials utilizing cognitive-behavioral strategies and regular telephone contacts have higher participation rates than others [38]. High retention rates (92% after 6 months) were reported in a physical activity plus behavioral intervention program with centre-based and home-based initiated approaches in middle to older aged women [42].

Conclusion

This paper has reviewed the recent literature on a topic that is of increasing interest for clinicians and researches trying to improve treatment outcomes for older patients with mental illnesses such as depression and cognitive impairment.

It can be seen that physical activity, like a number of other lifestyle interventions, holds the promise of better mental health outcomes for older adults. Such an intervention has the advantage of being safe and inexpensive and produces a wide range of health benefits. However, it is still necessary to wait for the convincing results of randomised trials that will systematically investigate the use of physical activity as a primary preventative strategy for dementia and depression in later life.

Competing interests

None declared.

Acknowledgements

This work was partly funded by projects grants to NTL, OPA and LF from Healthway (Western Australia), Rotary Health Research Fund (Australia) and the National Health and Medical Research Council of Australia (NHMRC).

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Articles from Annals of General Hospital Psychiatry are provided here courtesy of BioMed Central

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